Development and validation of a tool to measure knowledge and attitudes about traditional male circumcision and the links with HIV transmission in Indonesia

Abstract

Background Medical male circumcision has been recommended as a strategy for reducing HIV transmission as it is associated with a reduced risk of HIV infection. There is limited evidence on how traditional male circumcision (TMC) practice including risky sexual behaviours following the cultural practice may lead to HIV transmission although it remained practiced in low middle-income countries as a rite of passage into manhood. TMC practice was shrouded in secrecy and exclusivity leading to health risks including HIV transmission and challenge for health intervention programs. Given the absence of validated tools to measure knowledge and attitude on TMC and HIV transmission, the purpose of this study was to develop and validate a validated tool on knowledge and attitude on TMC and HIV transmission among the Indonesian general population. Methods This study was conducted among Indonesian men irrespective of their circumcision status. The questionnaire was developed from the literature review and then underwent a series of validation including content validity, face validity, test-retest reliability, and exploratory factor analysis (EFA). Results The factor analysis with 140 participants resulted in two factors with a total of 8 items in knowledge domain and 6 items in attitude domain. The Kaiser-Meyer Olkin (KMO) test for the knowledge factor was 0.759, and for the attitude factor was 0.797, with Bartlett’s test of sphericity p-value < 0.001 indicating that the data were suitable to proceed with further factor analysis. The scale content validity index (S-CVI) for knowledge and attitude was 0.83 and 0.89 respectively. The Cronbach alpha value for knowledge was 0.861 and 0.824 for attitude, suggesting good internal consistency. Convergent validity was confirmed by a moderate correlation ranging from r = 0.262 (p ˂ 0.01) to r = 0.703 for knowledge factor, and attitude factor ranging from r = 0.266 (p ˂ 0.01) to r = 0.823 (p ˂ 0.01). Conclusion The results provided evidence of validity of the knowledge and attitude towards TMC and HIV transmission among men aged 18 to 49 years regardless of their circumcision status in Indonesia. The questionnaire is a valid and reliable tool to assess the Indonesian public knowledge and attitude on TMC and HIV transmission.